Leadership for integrated care: A case study

Purpose. Integration of health services involves multiple interdependent leaders acting at several levels of their organisation and across organisations. This paper explores the complexities of leadership in an integrated care project and aims to understand what leadership arrangements are needed to enable service transformation. Design/Methodology/Approach. This case study analysed system and organisational leadership on a project aiming to integrate primary and specialist care. To explore the former, the national policy documents and guidelines were reviewed. To explore the latter, the official documents from the transformation team meetings and interview data from seventeen healthcare professionals and commissioners were analysed using thematic analysis with the coding framework derived from the comprehensive and multilevel framework for change. Findings. Although integration was supported in the narratives of the system and organisational leaders, there were multiple challenges: 1) insufficient support by the system level leadership for the local leadership, 2) insufficient organisational support for (clinical) leadership within the transformation team, and 3) insufficient leadership within the transformation team due to disruptions caused by personnel changes, roles ambiguity, conflicting priorities, and insufficient resources. Practical implications. This study provides insights into the interdependencies of leadership across multiple levels and proposes steps to maximise the success of complex transformational projects. Value. This study’s practical findings are useful for those involved in the bottom-up integrated projects, especially the transformation teams’ members. The case study highlights the need for a toolkit enabling local leaders to operate effectively within the system and organisational leadership contexts.

Local enhanced services: Is a lack of outcome data affecting diabetes care?

The Local Enhanced Service (LES) is a popular commissioning tool to boost the quality of health care. Primary care providers are invited to participate in the LES and offered financial incentives. There are many LESs for Diabetes across the UK, creating opportunities for comparing their variation in content and determining best practice. However, little is known about the individual LESs and their outcomes. Calling on mostly unpublished Clinical Commissioning Groups’ documents, this paper discusses the current practice in Diabetes LESs and highlights a need for their systematic evaluation

Population health management in diabetes care: combining clinical audit, risk stratification, and multidisciplinary virtual clinics in a community setting to improve diabetes care in a geographically defined population. An integrated diabetes care pilot in the North East Locality, Oxfordshire, UK

Background: Disparities in diabetes care are prevalent, with significant inequalities observed in access to, and outcomes of, healthcare. A population health approach offers a solution to improve the quality of care for all with systematic ways of assessing whole population requirements and treating and monitoring sub-groups in need of additional attention. Description of the care practice: Collaborative working between primary, secondary and community care was introduced in seven primary care practices in one locality in England, UK, caring for 3560 patients with diabetes and sharing the same community and secondary specialist diabetes care providers. Three elements of the intervention included 1) clinical audit, 2) risk stratification, and 3) the multi-disciplinary virtual clinics in the community. Methods: This paper evaluates the acceptability, feasibility and short-term impact on primary care of implementing a population approach intervention using direct observations of the clinics and surveys of participating clinicians. Results and discussion: Eighteen virtual clinics across seven teams took place over six months between March and July 2017 with organisation, resources, policies, education and approximately 150 individuals discussed. The feedback from primary care was positive with growing knowledge and confidence managing people with complex diabetes in primary care. Conclusion: Taking a population health approach helped to identify groups of people in need of additional diabetes care and deliver a collaborative health intervention across traditional organisational boundaries

Barriers and facilitators to integrating primary and specialist healthcare in the United Kingdom: a narrative literature review

Many national policies propose integration between primary and specialist care to improve the care of people with long-term conditions. There is an increasing need to understand how to practically implement such service redesign. This paper reviews the literature on the barriers to, and facilitators of, integrating primary and specialist healthcare for people with long-term conditions in the UK, with the aim of informing the development and implementation of similar initiatives in integration. MEDLINE and CINAHL databases were searched and 14 articles discussing factors hindering or enabling integration were identi-fied. The factors were extracted and synthesised and key lessons were tabulated. Successful integration of care requires synchronised changes on different levels, a well-resourced team, a welldefined and evidence-based service, agreed and articulated new roles and responsibilities, and a willingness among healthcare professionals to co-work and co-learn. Barriers to successful implementation of integrated care include a lack of commitment across organisations, limited resources, poorly functioning information technology (IT), poor coordination of fi nances and care pathways, confl icting objectives, and conflict within teams. The examples of integrated working provide insights into problems and solutions around interorganisational and interprofessional working that will guide those planning integration in the future

The potential for utilising in-hospital glucose measurements to detect individuals at high risk of previously undiagnosed diabetes: retrospective cohort study

Background Many people with undiagnosed diabetes have hyperglycaemia when admitted to hospital. Inpatient hyperglycaemia can be an indication of diabetes mellitus but can also indicate a stress response. This study reports the extent to which an in-hospital maximum observed random glucose measurement is an indicator of the need for in-hospital (or subsequent) HbA1c measurement to look for undiagnosed diabetes. Methods Blood glucose, HbA1c, age and sex were collected for all adults following admission to a UK NHS trust hospital from 1 January 2019 to 31 December 2020. We restricted the analysis to those participants who were registered with a GP practice that uses the trust laboratory and who had at least some tests requested by those practices since 2008. We stratified individuals according to their maximum in-hospital glucose measurement and report the number of these with HbA1c measurement ≥48 mmol/mol (6.5%) prior to the index admission, and during and after admission. We calculated an estimated proportion of individuals in each blood glucose stratum without a follow-up HbA1c who could have undiagnosed diabetes. Results In toal, 764,241 glucose measurements were recorded for 81,763 individuals who were admitted to the Oxford University Hospitals Trust. The median (Q1, Q3) age was 70 (56, 81) years, and 53% were males. Of the population, 70.7% of individuals declared themselves to be of White ethnicity, 3.1% of Asian background, and 1.1% of Black background, with 23.1% unstated. Of those individuals, 22,375 (27.4%) had no previous HbA1c measurement recorded. A total of 1689 individuals had a diabetes-range HbA1c during or after their hospital admission (2.5%) while we estimate an additional 1496 (2.2%) may have undiagnosed diabetes, with the greatest proportion of these having an in-hospital glucose of ≥15 mmol/L. We estimate that the number needed to detect a possible new case of diabetes falls from 16 (in-hospital glucose 8 mmol/L to <9 mmol/L) to 4 (14 mmol/L to <15 mmol/L). Conclusion The number of people who need to be tested to identify an individual who may have diabetes decreases as a testing threshold based on maximum in-hospital glucose concentration increases. Among those with hyperglycaemia and no previous HbA1c measurement in the diabetes range, there appears to be a lack of subsequent HbA1c measurement. This work identifies the potential for integrating the testing and follow-up of people, with apparently unrecognised hospital hyperglycaemia across primary and secondary care

Analysis of continuous glucose tracking data in people with type 1 diabetes after COVID-19 vaccination reveals unexpected link between immune and metabolic response, augmented by adjunctive oral medication

Introduction: The COVID-19 vaccination programme is under way worldwide. Anecdotal evidence is increasing that some people with type 1 diabetes mellitus (T1DM) experience temporary instability of blood glucose (BG) levels post-vaccination which normally settles within 2-3 days. We report an analysis of BG profiles of 20 individuals before/after vaccination. Methods: We examined the BG profile of 20 consecutive adults (18 years of age or more) with T1DM using the FreeStyle Libre flash glucose monitor in the period immediately before and after COVID-19 vaccination. The primary outcome measure was percentage (%) BG readings in the designated target range 3.9-10 mmmol/L as reported on the LibreView portal for 7 days prior to the vaccination (week −1) and the 7 days after the vaccination (week +1). Results: There was a significant decrease in the %BG on target following the COVID-vaccination for the 7 days following vaccination (mean 45.2% ± SE 4.2%) vs pre-COVID-19 vaccination (mean 52.6% ± SE 4.5%). This was mirrored by an increase in the proportion of readings in other BG categories 10.1%-13.9%/≥14%. There was no significant change in BG variability in the 7days post-COVID-19 vaccination. This change in BG proportion on target in the week following vaccination was most pronounced for people taking Metformin/Dapagliflozin+basal-bolus insulin (−23%) vs no oral hypoglycaemic agents (−4%), and median age <53 vs ≥53 years (greater reduction in %BG in target for older individuals (−18% vs −9%)). Conclusion: In T1DM, we have shown that COVID-19 vaccination can cause temporary perturbation of BG, with this effect more pronounced in patients talking oral hypoglycaemic medication plus insulin, and in older individuals. This may also have consequences for patients with T2DM who are currently not supported by flash glucose monitoring

Associations of microvascular complications with all-cause death in patients with diabetes and COVID-19:the CORONADO, ABCD Covid-19 audit and AMERICADO study groups

AIM: To provide a detailled analysis of the microvascular burden in patients with diabetes hopitalized for COVD‐19. MATERIALS AND METHODS: We analysed data from the French CORONADO initiative and the UK Association of British Clinical Diabetologists (ABCD) COVID‐19 audit, two nationwide multicentre studies, and the AMERICADO, a multicentre study conducted in New York area. We assessed the association between risk of all‐cause death during hospital stay and the following microvascular complications in patients with diabetes hospitalized for COVID‐19: diabetic retinopathy and/or diabetic kidney disease and/or history of diabetic foot ulcer. RESULTS: Among 2951 CORONADO, 3387 ABCD COVID‐19 audit and 9327 AMERICADO participants, microvascular diabetic complications status was ascertained for 1314 (44.5%), 1809 (53.4%) and 7367 (79.0%) patients, respectively: 1010, 1059 and 1800, respectively, had ≥1 severe microvascular complication(s) and 304, 750 and 5567, respectively, were free of any complications. The patients with isolated diabetic kidney disease had an increased risk of all‐cause death during hospital stay: odds ratio [OR] 2.53 (95% confidence interval [CI] 1.66‐3.83), OR 1.24 (95% CI 1.00‐1.56) and OR 1.66 (95% CI 1.40‐1.95) in the CORONADO, the ABCD COVID‐19 national audit and the AMERICADO studies, respectively. After adjustment for age, sex, hypertension and cardiovascular disease (CVD), compared to those without microvascular complications, patients with microvascular complications had an increased risk of all‐cause death during hospital stay in the CORONADO, the ABCD COVID‐19 diabetes national audit and the AMERICADO studies: adjusted OR ((adj)OR) 2.57 (95% CI 1.69‐3.92), (adj)OR 1.22 (95% CI 1.00‐1.52) and (adj)OR 1.33 (95% CI 1.15‐1.53), respectively. In meta‐analysis of the three studies, compared to patients free of complications, those with microvascular complications had an unadjusted OR for all‐cause death during hospital stay of 2.05 (95% CI 1.42‐2.97), which decreased to 1.62 (95% CI 1.19‐2.119) after adjustment for age and sex, and to 1.50 (1.12‐2.02) after hypertension and CVD were further added to the model. CONCLUSION: Microvascular burden is associated with an increased risk of death in patients hospitalized for COVID‐19

People with Type 2 Diabetes Mellitus (T2DM) Self-Reported Views on Their Own Condition Management Reveal a High Level of Insight into the Challenges Faced

From SAGE Publishing via Jisc Publications RouterHistory: epub 2021-05-17Publication status: Publishe